The Effects of Over-prescription of Anti-depressants - Coursework Example

12 April The Effects of Over-Prescription of Antidepressants When it comes to today’s society, there are many pressures. The economy is not good, many people are jobless, people are in debt, and people are always on the go. A person’s life has changed from being a more laid back type lifestyle to being one that is full of stress. To deal with these stressors in life and the feelings that people are feeling, they often turn to their doctors to see why they are feeling the way that they do. Unfortunately, it is not just a small handful of people but instead, on a much larger scale, there are more people on antidepressants now than ever before. In some instances, people who experience depression have it due to their biological make up. It can be a hereditary mental illness and not just a sad feeling. Instead, it can have to do with the genetic chemical combination in the brain that causes depression or depressive symptoms. There is a link between how the brain is made up and how it operates. People who have parents who have had depression are more at risk. Since this is generally a question acknowledged by medical history questions by primary care physicians, similar to whether or not a close biological family member had cancer or diabetes, physicians may seem to consider these patients more highly vulnerable and already stereotype a patient as someone who might potentially need antidepressants (Nixon, Liddle, Nixon, Worwood, Liotti, Palaniyappan). It is physicians who think like this that could serve as a link to the overprescribing of antidepressants in today’s society. People feel in crisis mode and are looking for an easy way out so that they do not have to slow down their busy days. The answer: a tiny wonder drug known as an antidepressant and its use has turned into a misuse. Now more than ever before, antidepressants are being more widely prescribed to people of all ages and pharmaceutical companies have developed a whole class of them with different active ingredients. Not only are patients in need of some sort of help for their depression but they are naïve to what the doctors prescribe them and on top of that, the pharmaceutical companies have so many different antidepressants on the market that it is all about trial and error for patients. When people do start to feel these emotions, they do visit their doctor. The doctor’s answer to this problem is generally a prescription written for an antidepressant so that people will start to feel a little less blue. Now depression has become a widespread diagnosis and even some of the antidepressants are used for other mental disorders other than just depression. Also, depending on the particular antidepressant, the side effects can be just as detrimental to the patient. While physicians are prescribing antidepressants at an incredible rate, it can be difficult for a patient to digest that they will need these. However, the trust that they have built up with their family physician puts them in a frame of mind that perhaps they do need to take antidepressants if their doctor suggests it. A patient must be willing to begin and continue this drug regimen and oftentimes and it heavily weighs on the trust of their physician’s professional expertise (Karp, 337). According to information from the Centers for Disease Control and Prevention (CDC), more than 1 in 10 Americans ages 12 and older take a type of antidepressant. From the years of 1988 to 2011, it was reported by the CDC that the prescription of antidepressants has risen over 400%. However, the CDC also acknowledges that there are many people that have severe symptoms of depression that do not take any antidepressants. More findings in this study acknowledge that the diagnosis of depression is very common and that over 9% of adults will experience depression at any point in their life and most of the people who have depression, it is twice as likely for women than men to be diagnosed with depression and to also take antidepressants (Szalavitz). While this is a mental struggle for many, there are many people out there searching for some type of help and some may even turn to the Internet to help self-diagnose. There are even online quizzes that people can take to see if they are feeling depressed. Some of the profiling questions are things like “I do things slowly,” “My future seems hopeless,” “I feel fatigued,” and “I am agitated and keep moving around,” (I. Goldberg). It is possible that with questions such as this, that many people often feel fatigued or move slowly. It does not always mean that they are depressed. An antidepressant is defined as a psychiatric medication given to people who have some type of depressive disorder. It is given in order to alleviate the symptoms and helps to alter the chemicals in the brain. Neurotransmitters in the brain can become imbalanced which causes the change in behavior and mood. Antidepressants were initially created in the 1950s and in the last 60 years, have become a common prescribed treatment to treat a wide range of psychiatric disorders. These include depression as well as anxiety disorders, mild chronic depression and social anxiety disorder, seasonal affective disorder and other psychiatric illnesses that people may have (Nordqvist). When it comes to the history of antidepressants, primary care physicians were to be the gatekeepers of detecting and treating people who had psychiatric illnesses. Since then, with the emergency of advances in psychopharmacology and chemistry, what doctors have used to treat people for their mental illnesses has changed quite significantly. Only in the last century have people really began to experiment with psychoactive drugs and used them to treat people for their illnesses (Lieberman, 6). Before psychopharmacology evolved, the most common method of treating people with mental illnesses of any kind was with lithium. Most of the time, it was used in insane asylums. However, depression was less prevalent then too and it was more severe mental illnesses that people had or went to doctors for. The use of lithium can be traced back to the late nineteenth century but in the early twentieth century, chemists began experimenting with other drugs to treat illnesses with drugs. Opiod alkaloids, a form of opiate, was then used to treat people who were depressed. Other methods were stimulants, electric shock treatment, and electroconvulsive therapy and they were common treatments that were almost inhumane methods of treating depression. Then a breakthrough was made in chemical pharmacology in 1952 that would change the way that depression was treated (Lieberman, 6). Antidepressants were discovered through the manipulation of molecules of antihistamines which then created an agent called chlorpromazine. This antipsychotic agent was like a tranquilizer but it helped to alleviate hallucinations and aggression. Researchers continued to work with antihistamines and through experimentation, the first modern antidepressants were created. Also, in 1952, an antimycobacterial iproniazid had properties that were psychoactive. While it was being tested as a potential treatment for people with tuberculosis, it was noted that patients that were even terminally ill who were given this concoction began to be more physically active, were more optimistic and acted more cheerful. Upon further breakdown of this drug, it showed that it slowed down the breaking down of enzymes in the brain such as serotonin, dopamine and norepinephrine. Further modifications were made and the first type of clinically useful antidepressant was created. Imipramine was the first tricyclic antidepressant (Lieberman, 6). Since the 1950s, antidepressants have become an increasingly common medication used in many households throughout the United States. There are approximately 30 different kinds of antidepressants that are available. Of these, there are five main types. These five types of antidepressants used include the following: tricyclics, monoamine oxidase inhibitors (MAOIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs) and noradrenaline and specific serotinagenic antidepressants (NASSAs). These all react with brain chemicals and neurotransmitters in the brain in various ways (Royal College of Psychiatrists). There are numerous common antidepressants (see table 1). There are numerous medications, common names and then their categories. Each category explains which brain chemicals each antidepressant inhibits. Table 1. Antidepressants that are commonly used, along with their given name and type of antidepressant that it is (Royal College of Psychiatrics). While all of the different types of antidepressants work a little bit differently but the main goal is to increase the activity of the neurotransmitter chemicals in the brain that fire signals from one cell to another. It is thought that the chemicals in the brain that are most associated with depression are noradrenaline and serotonin. Without testing a person’s brain chemistry, it is impossible to know for certain which chemicals are low and which are high, creating the imbalance and causing the depressive issues a person is experiencing in their lives (Royal College of Psychiatrists). Between the 1950s and 1970s, patients with depression were treated by psychiatrists. It was during this time that it was discovered that the tolerability of patients was good and SSRIs became the most preferred treatment of depression in primary care. Today’s primary care doctors are the most frequent prescribers of newer types of antidepressants in the United States though many depressed patients have never even been referred to a psychiatrist for more specialized treatment (Lieberman, 7). When visiting the primary care doctor, most patients who have depression actually start to see the doctor to seek help for symptoms that one would not necessarily associate with depression. People typically complain that they have more muscle aches, headaches, insomnia, decreased energy and other problematic feelings. They rarely actually visit their primary care doctor to discuss their emotional well-being. In one study, data concluded that on average, primary care physicians actually missed diagnosing major depressive disorder in approximately two-thirds of their patients who did actually have the illness which proves problematic for patients (Lieberman, 8). It appears that from these two variables that primary care physicians are not the ones that have the knowledge to diagnose a patient with depression nor are they the ones to dismiss it. It is questionable if they should be the ones that should also be the first prescribers of antidepressants due to their lack of specialization in psychiatric diagnoses. Misdiagnosis by primary care physicians of patients who either do or do not have depression could have to do with the increase in overprescribing antidepressants. It is suggested that due to the primary care physician’s relationship with the patient is very limited. Additionally, a primary care physician generally has a limited scope of knowledge in regards to psychiatry and psychotrophic drugs so it is a thought that those who suffer from depression or symptoms of depression should be immediately referred to a specialist in psychiatry (Johnson). According to the Royal College of Psychiatrists, antidepressants are not usually used for people who have mild depression though that can be argued because many doctors prescribe it in a variety of different scenarios. For the most part, antidepressants are designed to treat moderate to severe depression, chronic pain, eating disorders, post-traumatic stress disorder (PTSD), obsessive compulsive disorders (OCD) and severe anxiety and panic attacks. Over time, the formulas have changed and since each person’s body chemistry is different, so is their recommended dosage and type. It takes approximately one month for a person to feel a change after starting an antidepressant medication (Royal College of Psychiatrists). While traditional use of prescribing antidepressants has changed significantly in the last century from the use of lithium and opiates to the use of SSRIs or MAOIs, it is acknowledged that tricyclic antidepressants are less commonly used to treat depression. This is due to the fact that other antidepressants are generally more tolerable for the patient. The other types of antidepressants have less side effects (Liberman, 8). In contemporary medicine and use of antidepressants, it should be acknowledged that major depression actually is a common disorder. It is very disabling and has numerous social and economic repercussions. For those who are clinically diagnosed as having major depressive disorder, the response rate using today’s SSRIs in patients is effective in 60-70% of the population. It considered to be a highly tolerable medication. Even considering what types of antidepressants do work in contemporary medicine, it should be acknowledged that as more disorders are discovered with unique symptoms that can be treated with antidepressants, there is no doubt that through the use of pathophysiology that even more antidepressants will be developed (Andrews and Nemeroff, S24). Some people take different doses of their antidepressants. This could have to do with their weight. If they are on one particular antidepressant, a physician may simply just up the dosage if the current one is not working up until the patient is taking the highest recommended dose as set forth by the manufacturing pharmaceutical companies of these drugs. Some people may take their antidepressant once a day or even twice, depending on what it is and in different milligrams. Even newer antidepressants which are being developed are being designed with even more compounded pharmocokinetics. The properties of these antidepressants will change the dosages. The newer antidepressants are being created so that they stay in the body’s system longer. The current SSRIs have short half-lives of their active ingredients and may be in the bloodstream so that a person may take their antidepressant just once a day. Others may have half-lives of just two to five hours which requires patients to take them twice a day. If newer pharmocokinetics are put into place, the possibilities of antidepressants and their future is unlimited (DeVane, S13). Chemists and pharmacologists, in theory, may ultimately create an antidepressant that is active in a person’s body for a month. According to additional research, at least 11% of Americans over the age of 12 take an antidepressant. Approximately one-third of people with severe depressive symptoms take an antidepressant. Females are more likely to take antidepressants than males and compared to other races, non-Hispanic white people are more likely to take the medications (Pratt, Brody, Gu). At least 60% of Americans who have been taking antidepressants have taken it for over two years or longer. Of those people, 14% have been on medication for over a decade or more. Of those people who are on antidepressants, less than one-third of Americans take just one antidepressant. Of that one-third of the population, less than one-half of that population have even seen a mental health professional within the last given year (Pratt, Brody, Gu), which is an alarming statistic. This is a staggering statistic as one would think that mental health professionals, most particularly psychiatrists, would be the ones writing the prescriptions. However, since it is not a controlled substance, any physician or nurse practitioner can write the prescription and that is the reason many do. “Out of all of the patients I see, many of them seek antidepressants and I usually write scripts for Effexor though they all do something different,” said Katherine VanDyke, a nurse practitioner who has been practicing for well over a decade and has an overseeing doctor that knows everything she does (VanDyke). Antidepressants are the third most common drug prescribed by physicians that are taken by Americans of all ages during the years 2005-2008. They are mostly taken by people between the ages of 18-44 years of age. In the years 1988-1994 through 2005-2008, there has been an increase of 400% of people who take antidepressants among all ages in America. This includes all people who take antidepressants for any other issue besides depression since it is used to treat many anxiety disorders (Pratt, Brody, Gu). Besides antidepressants, therapy is one of the other most suggested ways to alleviate signs and symptoms of depression. According to research, when only four out of 10 people see a major difference in their symptoms of depression when trying an antidepressant for the first time. But there are also many fears people have when taking antidepressants and a lot of it comes from the potential side effects (J. Goldberg). Antidepressants will not make a person forget their problems. In theory, they are prescribed in order to make a person’s overwhelming issues a little bit more bearable. Antidepressants will not make them feel like they are in a trance. They are not always expensive medications and are often covered by insurance, which could be another reason why they are so widely acceptable and easily attainable. People may be afraid that it will be something that they will take their whole lives. Some people actually take antidepressants just for situational events in life such as a life transition, a death in the family or some other major life change. Others may take antidepressants as prescribed by their doctor for an extended period of time and it may be to treat more than just depression (J. Goldberg). There are some people that feel like that one little pill will cure all of their issues. Case in point is a person who has been on antidepressants since the age of 19 and is now 31. Ann Crandall started feeling anxious, feeling a little bit depressed at the overwhelming thoughts of being in college. Upon visiting the campus clinic psychiatrist on staff, she was immediately put an antidepressant called Lexapro. There were few questions asked and it was the doctor’s solution to try to get her to feel better about being in school. “I trusted what the doctor told me as he knew more about what my mind was going through than I did and I was even a psychology student in college. I just somehow had lost interest in doing the things that I used to do,” she stated in a personal interview (Crandall). “Now, more than a decade later, I have fought through depression and anxiety struggles and have tried numerous anti-depressants.” Crandall stated that she had been prescribed Lexapro, which seemed to help alter her mood for a few years and then her body became intolerant. Since then, she has been prescribed other anti-depressants such as Cymbalta, Paxil, Zoloft, Viibryd, and Effexor and when one did not work, the doctors prescribed benzodiazepines that are often addictive to help curb the depression and jittery feelings. Crandall stated that she felt taken advantage of by doctors and thought that major pharmaceutical companies gave kickbacks to physicians that prescribed anti-depressants as it seemed to have become a money game (Crandall). When it comes to the legality of the prescription of antidepressants, practitioners can be sued if they are violating their state’s standard of care laws. Each state varies but the norm is that the standard of care is what a reasonably prudent doctor in a similar or the same field will do. While there are studies that discuss health risks such as stroke, death, increase in suicide, etc. have been performed and evaluated, the research is not totally conclusive. If a practitioner prescribed it in a manner that most other practitioners would not, then are they subject to medical malpractice lawsuits (Andrews, Gott and Anderson-Thomson). Some lawmakers are becoming increasingly concerned with the overprescribing and types of antidepressants being used. The SSRI category of antidepressants are a newer class of medication. It often increases the potential of the risk of suicide among people that take it, particularly in children. Though there is no strong evidence to support it, lawmakers at this point cannot do anything. However, they are aware and continue to remain cautious about the use of SSRIs in pediatrics (Ludwig and Marcotte, 249). One thing that prescribing physicians must do is to provide information for the patient. Patients must be given any information about potential risks. This is evident when one picks up a prescription and the possible side effects, warnings and other pertinent information and labels are usually printed and distributed with the medication. When it comes to a primary care physician to be actually held liable for prescribing an antidepressant, a malpractice lawsuit involving a patient that was prescribed an antidepressant can only be won if the antidepressant can be proven that it harmed the patient or in somehow exacerbated the harm to the patient. This could involve a patient who takes one medication is put on an antidepressant that the prescriber knows will interfere with each other or if the patient already has issues that an antidepressant will make worse (Andrews, Gott and Anderson-Thomson). One effect that some doctors do not mention is one that affects many people who have taken antidepressants. Not only do people have to worry about possible side effects but after discontinuing an antidepressant, the likelihood of relapse increases. When a person stops taking the antidepressant in comparison to a placebo, at the three-month mark, 21% of people went into relapse. If the person is taking an SSRI categorized, the risk is twice that at 43%. If the antidepressants are even more potent, the risk of relapse is even higher than that. What some physicians do not tell is the rest of the story (Andrews, Gott, and Anderson-Thomson). After 60 years, it can be difficult to fully determine the long term effects but antidepressants have been proven to kill neurons and cause structural damage in the neurological system. This can lead to diseases such as Parkinson’s and due to the killing of neurons, it shows that prolonged use can have negative cognitive effects. In studies on rodents, antidepressants have been shown to impair the ability to learn new tasks. In research on older women who have used antidepressants for a prolonged amount of time, 70% of these women had an increase in the development of dementia and slight cognitive impairment. Antidepressants also are not acknowledged to increase the risks of breast cancer though they often do (Andrews, Gott and Anderson-Thomson). When it comes to over-prescribing, a study was done in the United Kingdom and researchers indicated that results were similar in Western countries such as the United States and Canada. When looking at a series of 153,931 patients, there were 2,108,311 prescriptions written and these people were considered stable and not depressed so they were getting medication to treat something else. Of 189,851 patients who were actually diagnosed as depressed, there were 2,093,737 prescriptions written. Of those patients, a total of 153,914 (over 81%) obtained at least one prescription for antidepressants (Moore, Ming Yuen, Dunn, Mullee, Maskell, and Kendrick). When most patients were first diagnosed with a depression illness, they were usually given a prescription for antidepressants. Over 74% of people who were first diagnosed received a prescription for an antidepressant within their first year of diagnosis instead of some other treatment of depression such as talk therapy. Many people were first given prescriptions for 30 days or less. However, by 2005, the percentage of people who were getting prescriptions for longer durations went up significantly. The majority of prescriptions were given as long term treatments or to those patients who had numerous episodes of depression. Between the years of 1993 and 2005, the total volume of prescribing antidepressants has more than doubled (Moore, Ming Yuen, Dunn, Mullee, Maskell, and Kendrick). According to this study, antidepressant prescribing has been on the rise for quite some time. The increase is not because of new cases of people with depression. Conclusively, this study in the United Kingdom stated that it was because more patients were becoming reliant on the antidepressant medications and were on them for long-term treatment (Moore, Ming Yuen, Dunn, Mullee, Maskell, and Kendrick). Of the top ten best-selling drugs in 2011, two were antipsychotic drugs. These two drugs treat several mental illnesses but the primary use of these two are as antidepressants. Abilify and Seroquel were listed. Abilify brought in $4.6 billion while Seroquel brought in $4.4 billion. The money spent by people on these drugs is nothing mundane. These were only listed among common drugs that were used to lower cholesterol, control asthma, help with digestion, and to control diabetes. Of these drugs, commercial insurance pays for part of it while the federical government, including Medicare and Medicaid, pays a large co-payment (DeNoon). The effects that these medications being overprescribed could potentially linked to a primary care physician over-diagnosing patients with depression. When statistics show that the majority of the prescribers of antidepressants are primary care physicians and many of those patients had never seen a psychiatrist or mental health care professional, one has to wonder. A general doctor knows a little bit about a lot of different medical issues. However, when it comes to illnesses of the mind, they cannot completely understand everything and their wealth of knowledge is a very minimal scope. Because of this, people may be misdiagnosed. Since they trust their health care provider, they start to believe that maybe they are depressed. Just because they have a few symptoms of depression does not necessarily mean that they fit the DSM-IV categorization of clinical depression characteristics. Since someone tells them that they are depressed, they believe it. They believe that they need the prescription to feel better simply because they are putting their trust in their healthcare provider. When being diagnosed with something, a patient may truly think they are depressed whether they really are or not. This can be detrimental on their emotions. To be diagnosed with anything is difficult and when it is a diagnosis of something of the mind, it can be devastating to the patient. Due to this diagnosis, they really might start to withdraw and stop doing things that they enjoy doing and only then do the patients actually start to feel the true symptoms of depression simply because a practitioner told them that they were. A misdiagnosis can be grounds for malpractice in any case. However, when the health care provider insists that a person will feel better if they take antidepressants, then they go and get the prescription filled. This is money out of their pockets that they could use for other things besides medication that is not necessarily needed. When one person is down on themselves, they can bring others down with them too. A nation full of depressed people can make a huge impact on the rest of society. One way to eliminate this problem is to turn to lawmakers and limit what they have the ability to prescribe. Some drugs, such as benzodiazepines are already limited to specialists in the field of psychiatry. So why shouldn’t antidepressants be regulated in the same way? Though it is not a problem that can be fixed overnight because now many people are reliant on them and often fear any withdrawal symptoms from coming down off of antidepressants, patients seem to be stuck. They are stuck among a nation full of healthcare providers that are willing to diagnose numerous people with depression, whether they are or not. They are stuck among money hungry insurance and pharmaceutical companies that give kickbacks to these doctors and worst of all, they are stuck believing that they need these antidepressants in order to function. Whether it be through media or some other method, awareness about the overprescribing of these medications need to be acknowledged. It seems that no one wants to even touch the subject or acknowledge that it even exists. However, the facts are there and society as a whole is feeling the impact as their money goes toward doctor’s appointments and pharmaceutical companies for these expensive drugs. Works Cited Andrews, James and Charles Nemeroff. “Contemporary Management of Depression.” The American Journal of Medicine. 97(6):1. S24-S32. 19 Dec. 1994. Andrews, Paul, Lyndsey Gott and J. Anderson-Thomson, Jr. “Things Your Doctor Should Tell You About Antidepressants.” Mad In America: Science, Psychiatry and Community. Mad in America, Inc. 12 Sept. 2012. 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Karp, David. “Taking Anti-Depressant Medications: Resistance, Trial Commitment, Conversion, Disenchantment.” Qualitative Sociology. 16(4). 1993. Print. Lieberman, Joseph. “History of the Use of Antidepressants in Primary Care.” The Primary Care Companion Journal of Clinical Psychiatry. 5(7): 6-10. 2003. Print. Ludwig, Jens and Dave E. Marcotte. “Anti-depressants, Suicide and Drug Regulation.” Journal of Policy Analysis and Management. 24(2): 249-272. 2005. Print. Moore, Michael, Ho Ming Yuen, Nick Dunn, Mark A. Mullee, Joe Maskell and Tony Kendrick. “Explaining the Rise in Antidepressant Prescribing: A Descriptive Study Using the General Practice Research Database.” BMJ 2009; 339:b3999 15 Oct 2009. Web. 15 April 14. . Nordqvist, Christian. “What Are Antidepressants?.” Medical News Today. Medical News Today, 12 July 2012. Web. 12 Apr. 2014. . Nixon, N.L., P.F. Liddle, E. Nixon, G. Worwood, M. Liotti, and L. Palaniyappan. “Biological Vulnerability to Depression: Linked Structural and Functional Brain Network Findings.” The British Journal of Psychiatry. 204(4). 2014. Print. Pratt, Laura, Debra Brody, and Qiuping Gu. “Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 19 Oct. 2011. Web. 13 Apr. 2014. . Szalavitz, Maia. “What Does a 400% Increase in Antidepressant Use Really Mean?” Time. Time, 20 Oct. 2011. Web. 12 Apr. 2014. . VanDyke, Katherine. Personal interview. 13 April 2014. Read More